The Other Way Around

The ever wonderful and erudite @MentalHealthCop has written this superb blog as his statement to the Care Quality Commission ahead of their review of Emergency Mental Health Care.

Michael really has covered just about everything that needs to be said but I have a few observations of my own.

Broadly speaking these can be condensed into two questions I would like the CQC to consider.

1. What *is* a crisis?
2. Who is currently providing emergency mental health care and who SHOULD be providing it?

What *is* a crisis?

I have blogged before on the apparent capability of Emergency Duty Teams to deflect work until such time as they absolutely have to get involved.

Last week, I managed an incident involving a suicidal person who had barricaded themselves into their flat on the fifth floor of a high-rise block of flats.

This person had been drinking and had taken an overdose of tablets. Although they were engaging my officers through the door the situation was made quite clear – “if you try and come in, I will jump.”

Where do you go from there?

The answer is simple but lengthy. You keep talking to them. For as long as they are talking they are alive and there is a chance that this talking will lead to a successful resolution.

For this task I called in specialist negotiators who took a while to get there. In the meantime, my officers, a friend and some suicide intervention trained paramedics kept things going.

My next task was to try and mitigate a jump or fall. After much consideration and discussion with a Tactical Advisor and the Fire Service Incident Commander I decided that we couldn’t mitigate it at all.

Nothing exists which can break a fall from that height and the use of the Fire Service’s ladder would have been noisy and could have pre-empted the situation.

So we carried on talking.

I then had a discussion with the Paramedic Commander where we discussed options. Particularly in relation to what powers we had to enter and do something positive if we needed to.

The answer to that was that whilst the police could force entry to save the person – once inside they couldn’t actually save the person or take them away without criminalising them or arresting them to prevent a breach of the peace.

We had already made contact with the Crisis Team but they had told us they had no prior knowledge of the individual and that was it.

I asked one of my sergeants to contact them again and ask them to consider a Section 135(1) Warrant which might allow us to go in and assess the person or take them away for assessment.

The callback I got from the Sergeant effectively told me that the Crisis Team didn’t know how to get a 135(1) Warrant and he wasn’t even sure they knew what one was.

Which left us with the Ways and Means Act to get this resolved.

Eventually, the suicidal person agreed to meet a police officer on the balcony and, using the cherry-picker, this officer was elevated five floors, went over a balcony and met the person as they came out.

As soon as they were his arms I gave the order to put the door in.

The situation was safely resolved.

Except it wasn’t. It was safe but it took another hour of negotiation to persuade this person to go to hospital voluntarily as none of us there had any powers to do anything else.

At the conclusion of this three hour incident I can safely say that I do not believe that the person was mentally ill though I believe that their suicidal intentions were genuine.

We couldn’t be sure of that until we actually got into the premises and made a better assessment.

The operation used about 30 emergency service personnel. Three incident commanders with me leading. Several ambulances, police vehicles and a fire tender with a massive mechanical ladder.

Where were the Crisis Team?

I needed them to do one thing to assist and they didn’t / couldn’t / wouldn’t do it.

The legal loophole needs to be closed which makes a 135(1) warrant necessary but so does the culture which can be summed up thus:

We don’t know for sure that they are mentally ill yet.

It is still a crisis. It is still dangerous and someone’s life is potentially at risk.

Another example would be “they are drunk”.

So many times I have been involved in cases of suicide intervention or potential mental health disturbance in a private place but because there is evidence or a suggestion that the person is drunk the Crisis Team flatly refuse to engage.

Instead they suggest that the person is arrested to prevent a breach of the peace. Then the police take them to cells to sober up for several hours before EDT will even entertain assessing them.

Don’t get me wrong. You cannot properly assess someone who is intoxicated. The questions are:

How do we resolve the situation NOW and whose responsibility is it?

Which leads me to my second point.

Who is currently providing emergency mental health care and who SHOULD be providing it

I made no secret of my disappointment at the HMIC report into police use of cells for Section 136 detainees.

This was a massively missed opportunity and I agree with Michael entirely when he says that you will never get parity between physical and mental health care for as long as you are locking up sick people in cells.

A police station custody suite is NOT an appropriate place of safety – in my humble opinion.

Why isn’t it?

Partly because of what it is. It’s a cell complex where we detain suspected criminals. Hardly the right place for anyone suffering a disturbance of the mind and WHY should they go there anyway?

Mostly because they are not equipped for it, the staff are not trained for it and the required emergency medical provision is not accessible.

If you deal with a MH crisis in a hospital setting then there are very clear guidelines on how to do it and what needs to be in place.

Deal with this same medical emergency in a police custody unit and none of these things are in place.

Same situation – different settings – different responses.

Parity? I think not.
Fair? I think not
Safe? I know not

There can be absolutely no doubt that the provision of mental health care across the country is not currently coping with demand.

Equally, I do not believe that the responsiveness of Crisis Teams has moved with the times either.

They are under resourced and have come to expect the police to deal with things until such time as everything is largely sorted.

Their role cannot simply be to turn up to a police cell for an assessment when someone is sober or calm.

By then the “crisis” is usually over.

Chances are they won’t be talking to the same agitated individual the police have been sitting with for the previous 6 hours.

The role and resources of the Crisis Team needs to be reviewed and changed. We should be working TOGETHER!

Their role in suicide intervention needs to be clarified and enhanced.

We need to agree what we are going to do with “drunk” people before they can be assessed.

We need to provide properly equipped places of safety.

We need to train our staff properly – accepting the reality that police WILL be dealing with emergency MH incidents.

We need Crisis Teams who will help obtain 135(1) Warrants and come to the scene of a crisis.

We need to understand each others roles and responsibilities better.

We need to be working as a team rather than in the silos we are currently operating in.

We need hospital bed spaces and a Crisis Team – not police cells and an “After The Crisis” Team.

This review is the chance to really examine this closely and truly assess current and future demand and whether any of the services involved are properly resourced, equipped or trained to deal with it.

Ultimately this is a HEALTH problem where other agencies have a part to play.

Right now – it often feels like it is the other way around.

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6 responses to “The Other Way Around”

Is this a joke? So a drunk person threatening self harm is an “ill” person requiring medical attention? Not sure which med school you went to.In reality it’s a difficult pers on you don’t know what to do with.Your answer: send a nurse to the house to do what precisely?Apart from putting themselves and the person at more risk. Have a nice chat? Put the kettle on? Remember vast majority are not ill. Precisely what the antipsychiatry movement predicted many years ago. Call it “illness” and medicalise it. Funny thing is though,it’s always people outside frontline psychiatry who do that. Emergency situation=Emergency Service.

Regarding the crisis team inabilty to obtain a section 135 (1) warrant. Crisis teams (in my area) are now entirely made up of health staff (CPN’s, OT). Only AMHP’s can apply for a 135 (1) warrant and very few Crisis teams will have an AMHP attached to them anymore. Even if they did if it was out of hours the Crisis team AMHP is likely to be on their own and forbidden to leave the office as then they are unable to take the crisis calls they are employed to take (and despite the criticism that Crisis teams receive they do excellent work with very distressed people but this is rarely recognised).
The EDT team should have AMHP’s able to obtain a 135 (1) warrant. In my area it would probably be a 2-3 hour job depending on where the duty magistrate lived and time of evening/night.

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